History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnosis
Testing
Test Results
Test Interpretation
Diagnosis
Treatment Orders
Question 1
Question 2
About the Case
Exertional Dyspnea in a 76 YO Man
Review of Systems
General
: Patient generally feels fatigued. No recent weight changes.
Skin
: No rashes or skin lesions.
HEENT
: No vision changes, ear pain, nasal congestion or discharge, or sore throat.
Pulmonary
: See HPI
Cardiovascular
: See HPI
Gastrointestinal
: Good appetite. No abdominal pain, nausea, vomiting, or change in bowel patterns.
Genitourinary
: Has not produced urine for several years since beginning dialysis. Has not missed any dialysis treatments.
Musculoskeletal
: No redness or pain in extremities. He has noticed increased swelling of his feet and ankles in recent months.
Neurologic
: Noncontributory
Psychiatric
: Noncontributory
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